Experience is key in weight surgery

Insurer urges use of quality programs

New data gathered by Blue Cross and Blue Shield of North Carolina show that weight-loss surgery can be done safely and with a low rate of complications when experienced surgeons follow strict clinical guidelines and patient selection standards.

The findings are significant because severely overweight people still often have difficulty persuading health insurers to pay for bariatric surgery, which shrinks the stomach and reroutes food through the digestive tract in a way that helps many patients achieve dramatic weight loss. In recent years, many insurers restricted or rescinded coverage for such surgeries, citing the procedures' high rates of complications.

Different approach

But Blue Cross took a different approach. In 2004, it continued to cover bariatric surgery while urging patients to seek out high-quality surgery programs. "Centers of excellence" were selected based on how many bariatric surgeries they had performed and the outcomes of those procedures. Last week, Blue Cross released initial results of its program.

The insurer found that, between October 2004 and October 2005, hospital readmission rates for patients dropped by nearly half among the 12 North Carolina surgeons Blue Cross designated as a "center of excellence." Less than 5 percent of the 12 surgeons' patients had to be readmitted to the hospital within 30 days of their surgery. In 2003, before the Blue Cross excellence program was in place, the 12 surgeons readmitted 7.6 percent of bariatric patients.

The same year, Blue Cross estimated the rate of hospital readmission among non-center of excellence surgeons at 16.4 percent. Surgeons who were not designated as centers of excellence also improved: In 2004, the hospital readmission rates among that group fell to 8.6 percent.

"It's sort of a raising-all-boats phenomenon," said Dr. Robert Harris, chief medical officer for Blue Cross. "Physicians are a pretty competitive group. Most are going to want to show improvement."

Blue Cross has since broadened the program to include four additional surgeons, for a total of 16 centers of excellence providers.

Quality program

Blue Cross was one of the first health plans nationally to develop a quality program for bariatric surgery, which has remained in high demand among morbidly obese patients amid concerns about safety. Nationally, the American Society of Bariatric Surgeons expects 177,600 weight-loss surgeries to be performed this year, up from 171,000 in 2005. The average cost of surgery, without complications, is about $25,000. Blue Cross pays higher rates to center of excellence providers, Harris said.

In North Carolina, Blue Cross paid claims for 673 bariatric surgeries in 2005, spokeswoman Rita Simonetta said. During the first six months of this year, the insurer has paid claims for 360 procedures. A person generally must be at least 100 pounds overweight to be a candidate for bariatric surgery. Often, patients also have additional health problems, such as diabetes or imminent physical disability due to obesity.

When bariatric surgery is done correctly and patients change their diet and exercise habits, it results in lasting weight loss. But it is not just a cosmetic procedure. The surgery can reduce some of obesity's worst accompanying problems, such as diabetes, high blood pressure, arthritis pain and sleep apnea. Even when performed by the best surgeon, however, weight-loss surgery can result in serious and even life-threatening complications such as intestinal ruptures, internal bleeding, infection, severe malnutrition, vomiting and acid reflux.

"The problem has been that everyone has been doing it and they didn't have the systems in place to ensure quality," said Dr. Walter Pories, 76, a professor of medicine at East Carolina University who began doing bariatric surgery in the early 1980s. He still sees patients but quit performing surgery when he turned 70. "Once you have the systems in place, the safety is remarkable."

An experienced surgeon is just part of the equation. Pories said outcomes also depend on having experienced nurses who can quickly spot signs of complication.

Patients also play a vital role in their own success, he said. Patients, whose stomachs are essentially reduced to the size of a golf ball, must drastically cut the amount of food they eat and must chew more slowly during meals. They also must take vitamin and mineral supplements to replace the nutrients they are no longer getting from food, Pories said, or risk becoming malnourished.

"People need to understand that this is not for all morbidly obese people," Harris said. "But it clearly has a place in the armament of treatments."